Sleepless nights cost billions in care and productivity

The continual inability to fall asleep or stay asleep is keeping approximately one-third of the nation up at night. In 2007, the Department of Health and Human Services reported more than 64 million people are affected by short-term or long-term insomnia.

Anna Silberman, vice president of preventive health services for Highmark Blue Cross Blue Shield in Pittsburgh, believes sleep should be routinely recognized as a vital sign.

"Sleep is necessary for overall good health," she says. "We need to understand that there is a definite link between sleep and chronic conditions, such as diabetes and depression."

Chronic insomnia, which often impairs daytime functioning, calls for treatment by a physician and pharmacist, and offers an opportunity for a health plan to help manage the condition.

At least 30% to 40% of people report some difficulty with sleep (transient or intermittent). Chronic insomnia, which may persist for weeks, even years, affects at least 10% of adults.

Individuals with insomnia incur $12 billion in direct medical costs and $2 billion in drug costs alone, according to Hyong Un, MD, national medical director, Aetna Behavioral Health. Whole societal costs, including healthcare costs and productivity, add up to $80 billion or more in economic impact.

Indirect insomnia costs often can be linked to lost productivity due to absenteeism or "presenteeism" (being present at work but with impaired functioning). A study by the University of Michigan Department of Psychiatry and Neurology found that people with insomnia miss work twice as often and have a higher rate of work accidents and errors.

The University of Michigan study also found that the per-member per-year cost for patients with chronic insomnia is $2,800. According to JestaRx, a pharmaceutical marketing firm, prescription drug costs for patients with insomnia is $1,220 versus $422 for those without insomnia, Generally, those with insomnia have higher healthcare use with a two-fold increase in hospitalizations and office visits. The condition often is comorbid with other costly conditions and behavioral disorders.

"In other instances, there may be a medical reason why you might have insomnia [such as arthritis, a cardiac condition or COPD]," Dr. Un says. "These are all secondary medical causes of insomnia. Before you start treating secondary insomnia with medical treatment approaches, try to rule out comorbid causes."

DRUG TREATMENT APPROACHES

A Medco Health Solutions analysis shows that use of prescription sleep medications skyrocketed 52% for adults ages 20 and older between 2001 and 2006. In the age group of 65 and older, medication use increased a significant 26% during the analysis period. Research also found that women are 60% more likely than men to take prescription sleep medication.

Prescription medications for insomnia, according to the Institute of Medicine (IOM), fall into several categories: benzodiazepines, benzodiazepine-receptor agonists, nonbenzodiazepines, sedating antidepressants, barbiturates, and anticonvulsants. The U.S. Food & Drug Administration advises the lowest dose possible when using sleep drugs and that patients use them only for a short time and intermittently, especially if a patient starts experiencing better sleep cycles.

"Benzodiazepines and nonbenzodiazepines, as well as drugs not indicated for sleep necessarily, are effective for the short term, episodically for less than four weeks," Dr. Un says. "For longer-term use, these typical prescription-only drugs are not as effective."

Dr. Un adds that while over-the-counter antihistamines may be useful for the short term, their use warrants caution.

"These drugs often have residual daytime effects and may impair functioning, memory, reflexes, thought process, handling tools or driving," he says. However, he adds, "I don't want to mislead and say hypnotics are dangerous in the short term."

With some insomnia drugs, there are potentially serious safety issues. In March 2007, the FDA urged all manufacturers of sedative-hypnotic drug products to modify product labels to strengthen language on potential risks, including severe allergic reactions and activity while asleep (such as driving) with no recollection upon waking.

More studies of long-term efficacy and side effects of insomnia drugs are needed, experts say.